Muscle Re-education

Ass. Prof. Salwa Roushdy

08/05/23 Ass. Prof. Salwa Roushdy 1

  Lecture 1 Muscle Re-education

 Objectives of the Lecture

 
At the end of the lecture the students will be able to:
 Be familiar with a general introduction and definition on muscle re-education.
 Know the ultimate goals of muscle re-education.
 Be oriented to the administration of different muscle re-education techniques.
 Define the concepts of strength, co-ordination and endurance.
 Recognize the factors affecting muscle re-education.
 Be aware how to practically re-educate muscles.
 Know the concepts of muscle re-education.
 
Contents of the Lecture
 
 Introduction and definition of muscle re-education.
 Objectives of muscle re-education.
 Indications for muscle re-education.
 Pre-requisites for muscle re-education.
 Techniques of muscle re-education.
 Examples.
 
 
 
 
 
08/05/23 Ass. Prof. Salwa Roushdy 2
 Definition •
 It is the phase of therapeutic exs developed to:
1. The development, or
2. The recovery of voluntary control of skeletal ms.

 Techniques of motor learning or re-learning are grouped

together under the single term m. re-education.

 This leads to some confusion, because the approach to

learning & re-learning aren’t necessarily the same, even
though, each has certain principles in common.

 Lack of effective m. control may:

1. Result from many different causes &
2. Be manifested in many different ways.
08/05/23 Ass. Prof. Salwa Roushdy 3
 Objectives of m. re-education:

1. To develop motor awareness & voluntary motor response

(Re-learn the injured m. its ingram in the brain or
learning a new ingram for a new action for the ms).

2. To develop strength & endurance in patterns of mov. that are

necessary, safe & acceptable.

 1 & 2 are related to each other, that one could

hardly be achieved without the other.

 We must initiate development of 1. motor awareness

& 2. voluntary motor responses before we can set up
a program to develop 3. strength & 4. endurance.

 On the other hand, some degrees of strength & endurance are

necessary to the development of motor awareness
& effective voluntary
08/05/23 response.
Ass. Prof. Salwa Roushdy 4
Necessary & Effective
Are used to emphasize a well-designed program of m.
re-education,
which must be based on very specific
& practical demands for: the pt & his
environment.

Safe
Safe
Safe patterns: which minimize the hazards of trauma &
deformity that might
→ abnormal stress & strain.
08/05/23 Ass. Prof. Salwa Roushdy 5
 Acceptable
Acceptable patterns of movs are designed to:
fit the handicapped pt into normal environment in
contact & in competition with
physically normal people.

Acceptable patterns are acceptable to normal people in a

normal environment.

It is of some academic interest to teach a young pt

to grasp a fork with his toes to feed himself.
But
This becomes completely unacceptable when he becomes
a young adult.
08/05/23 Ass. Prof. Salwa Roushdy 6
 Indications of M. Re-education
1. Diseases causing subnormal voluntary control.

2. LMNL → mild:severe flaccid paralysis & weakness of motor response

3. Dyskinetic mov as
a. Spasticity b. Athetosis c. Ataxia (sluggish) d.
Rigidity e. Tremors. f. Any combination of those.

4. UMNL: in flaccid stage → m. weakness.

5. After prolonged immobilization or disuse.

6. After tendon transfer or m. transplantation.

7. After arthroplasty.
08/05/23 Ass. Prof. Salwa Roushdy 7
Pre-requisites for m. re-education

1. Patient Evaluation:

 A detailed exam. of pt. is essential to adequate prescription

for m. re-education.

 Initial pt. exam consists of > a simple m. test from

which a prescription for m. strengthening can be written.

 P.T. awareness of the factors directly related to effective m.

re-education including his knowledge of the disease
& its natural course.
08/05/23 Ass. Prof. Salwa Roushdy 8
 General Physical & Mental Status .2
 Is a prerequisite for pt. eval. & m. re-education.

 Determine if the pt. is medically able to safely exercise.

 Extent of exam is dependent on background information of

nature & extend of disease.

 Determine if the pt. understand & follows directions.

“ “ if the pt. is interested in his own recovery.

 Many pts will refuse to cooperate due to conscious or unconscious feeling that
recovery would be disadvantageous for them.

• 1st prerequisite to re-educate m., is a co-operative pt , who:

1 - is consistent with his age.
2 - understand reasons for the program.
3 - wishing to recover whatever functional capacity is possible.
08/05/23 Ass. Prof. Salwa Roushdy 9
 Available Motor Pathways .4
 Central & Peripheral nervous system (CNS & PNS).

 The effective methods of determining state of neuromuscular excitability is

MMT for pts who show evidence of abnormality of m. response.

 Value of MMT: to know from where to start m. re-education.

 MMT requires: a thorough knowledge of functional anatomy &

kinesiology of human body.

 Use MMT or functional type of testing of carrying ADL.

 In MMT & functional activity test: inco-ordination, substitution, dyskinesia,

weakness or inability are necessary to be observed.
08/05/23 Ass. Prof. Salwa Roushdy 10
EMG gives information for diag. & prognostic state.

EMG gives data about:

1. Actual motor denervation.

2. Map out areas of silence & areas of polyphasic reactions,

indicating progressive denervation or recovery of innervation.

3. Galvanic current draw strength duration curve, & determining chronaxie

→ assess PNS injury.

M. re-education mustn’t only be based on the:

1. Site 2. Extent of m. strength, but also on
3. Possibilities of recovery, which will be indicated by these tests (MMT, EMG).

08/05/23 Ass. Prof. Salwa Roushdy 11

 Available Sensory Pathways .5
 Intact sensory & motor pathways are:
important for necessary for m. re-education.

 Extro & proprioceptive systems →

provide information to motor awareness.

 Its failure (sensory system) →

severe loss of voluntary response, even though the motor pathways are intact.

 Sensory system is tuned to m. tension , & its response is altered by:

1. motor unit denervation.
2. decay of m. strength through: disuse, prolonged stretching, development of substitute
patterns of mov.

 Loss of superficial or deep sensation:

plays a profound role in m. re-education.
08/05/23 Ass. Prof. Salwa Roushdy 12
 Muscle-Tendon Integrity & Mobility .6
 M. must be:

1. Intact throughout its length.

2. Stable at its origin & insertion before adequate response
can be expected.
3. Free to move within its normal components.

M. contracture M-tendon contracture Tendon stenosis

Loss of ability to contract effectively, even though the motor pathways are intact.

08/05/23 Ass. Prof. Salwa Roushdy 13

Relation of Tendon Length to M. Mass .7
 Ability of m. to move the segment it controls through desired
ROM depends in great part on the length of its tendon.

 If the tendon is contracted

-------» m. normally can accomplish a small portion of the R.

 If the tendon is lengthened -----» ineffective m. cont.

 Repeated stretching or lengthening of tendon

--------» permit m. mass to shorten &
--------» limit m. ability to contract through normal R
--------» disuse ------------------------» loss of m. strength.

 Any tendon lengthening manually or surgically should be avoided,

except when essential, to prevent severe deformity. 14
08/05/23 Ass. Prof. Salwa Roushdy
 Joint Mobility .8

Loss of jt. mobility has a profound effect on m. re-education.

Basic objectives of re-education can never be achieved

if the jt. through which the m. acts is frozen in one
position.

This doesn’t mean that a jt. has to be completely & normally

mobile, but at least it should be mobile through a functional R
before m. re-education.

08/05/23 Ass. Prof. Salwa Roushdy 15

 Skeletal Alignment .9
 Possibilities of m. re-education are directly related to
skeletal alignment.

 This is particularly true in structural changes in the

spine, legs & feet following:

1. Paralytic disease
2. Malalignment of # post-traumas.

08/05/23 Ass. Prof. Salwa Roushdy 16

 Pain

It is impossible to obtain co-ordinated mov.

if such mov → pain.

If this mov → pain

→ pt.’ll carry out the mov. by substitute patterns of
action
→ lessening the pain.

08/05/23 Ass. Prof. Salwa Roushdy 17

 Dyskinetic Movements

Abnormal motor activity due to UMNL

→ limit all attempts of m. re-education.

Classical m. re-education used when there is LMNL will be of:

little, if any value unless
the abnormal UMNL activity can be controlled.

08/05/23 Ass. Prof. Salwa Roushdy 18

 Techniques of M Re-education
 As m re-education is devoted to the:
1. Recovery of voluntary control of skeletal m., or
2. Development of motor control (active, strong, coordinated,
enduring), so

 The primary OBJECTIVES must follow

a certain REASONABLE order:
I. Activation
II. Strength
III. Co-ordination
IV. Endurance

08/05/23 Ass. Prof. Salwa Roushdy 19

 I. Activation
 If the pt can’t voluntarily contract a portion of m.,
or a m., or many ms. in either direct or associated movs
(with yawning) → there can be no degree of motor control.

 At that time m. re-education program must begin by applying

certain techniques to activate these LMNU.

 Techniques to activate LMNU:

A. Focusing procedures
B. Proprioceptive stimulations

 No one technique alone is adequate in all problems,

PT must know & use all possible techs. in
whatever combination → give optimum
response.
08/05/23 Ass. Prof. Salwa Roushdy 20
 A. Focusing Procedure
 All re-education techs. should be started with:
a discussion or demonstration of the routines to be
used.

 Pt. may not only know what is:

1. Being done? , but

2. Expected to do?:
1. if he is to relax, he must know
2. if he is to attempt to contract & when?,
All depends on the pt’s age & intelligence
08/05/23 Ass. Prof. Salwa Roushdy 21
 Passive Motion (PROM) .1
 1st step in starting activating LMNU.

 Can be done for completely denervated m.

 Pt shouldn’t assist or resist mov carried out.

 May be: 1. One-jt ” one plane, or multiple planes mov”.

2. Multiple jt mov, “single” or “multiple“ planes.

 Makes the pt. aware of desired mov by:

feeling & seeing the mov as they are carried out.

 Stimulates proprioceptive reflexes of flex, ext & stabilization.

 *** Passive mov is difficult to be executed properly.

 Arc & speed of mov must be altered until desired responses are obtained.

08/05/23
Begins within limits ofAss.
painProf.&Salwa
tightness,
Roushdy then progress. 22
 Cutaneous Stimulation .2
 Assist pt to concentrate on areas under care,
he can better see & feel cont. in specific ms.

 Has some proprioceptive stim value:

in infants & young children tickling & scratching various
areas → promote movs.

 The PT may use:

1. His fingers to: stroke or tap ms & tendons.
2. A brush or a rubber hammer.
3. Basic massage (effleurage, petressage, tapotement).
4. Cryotherapy (“brief“ ice application).
5. Brief painful stim..
08/05/23 Ass. Prof. Salwa Roushdy 23
 Electrical stimulation .3
Cause m. cont 1--» pt. see & feel m. cont.

2 --» sensations of value in

sensory reflex stim.

3 --» m. tension

4 --» proprioceptive stim.

08/05/23 Ass. Prof. Salwa Roushdy 24

 EMG & BFB .4
 Equipments with both visual & auditory output
→ assist pt more accurately contract his ms.

 ↑ colors, sounds & height of changes of elect. potentials

→ aid pt’s focusing on desired ms.

 Indications:
1. Spotty m. weakness
2. Reactivation of ms after tendon transplantation.
3. As a focusing & motivating method.

08/05/23 Ass. Prof. Salwa Roushdy 25

 B. Proprioceptive Stimulations
 Is an activation method → stim. m. cont. by proprioceptive stimulation
(jt, m, tendon), these receptors can be stimulated by:
1. Passive mov.
2. Positioning in various attitudes
3. Balance in sitting & crawling
4. kneeling & standing (righting reactions) → vestibular stim.
5. Weight bearing
6. Traction
7. Approximation
8. Quick stretches
9. Resistance

We must use posture, passive mov, active mov to → stretching, resistance &
reflexes necessary → stim. proprioceptive system.
08/05/23 Ass. Prof. Salwa Roushdy 26
 Stretching & Resistance
M. tissue responds best when:
extended & put under some tension (stretching).

Obtaining strength & co-ordination must be based on

techniques requiring m. to contract against resistance
when partially elongated.

Sudden stretching of m. or
sudden release of tension
→ facilitate active response.
08/05/23 Ass. Prof. Salwa Roushdy 27
 Reflex Stimulation
 Normal & Pathological reflexes → initiate:
1. M. cont
2. Righting reactions
3. Equilibrium
4. Protective reactions

 Normal & Pathological reflexes are essential steps in:

1. M. re-education
2. Functional training.

08/05/23 Ass. Prof. Salwa Roushdy 28

 II. Strength
 Definition:

1. Ability of m. to generate force or torque at a definite velocity.

2. Ability of a m. to develop force for providing:

1. stability (keep me stable).
2. mobility (strength to move).

3. Ability of a m to continue successive exertions under

conditions where a load is placed on it.

 Strength can be obtained only through m. work

08/05/23 (force x distance).
Ass. Prof. Salwa Roushdy 29
1. Training effect which is due to:
1. ↑ circ. &
2. development of m. sense through proprioceptive system.

2. Hypertrophy of m. f.

3. ↑ No. of motor units entering into the contractile effort.

4. Sprouting
(if motor units have been denervated,
some degrees of re-innervation will occur by
adjacent intact neurofibrils).
08/05/23 Ass. Prof. Salwa Roushdy 30
 Each of these factors demands ↑ R to the voluntary effort
→ max response.

 Workload must be appropriate to the MMT grade,

neither too little, nor too great.

 If the demands are minimal

→ only few units activated
& strength “ll be limited,
load must be built up as m. tolerate.

 Type of ex. for weak m. depends on:

1. Site of weakness.
2. Extent of weakness.
08/05/23 Ass. Prof. Salwa Roushdy 31
Very limited (specific) exs. are built up, if only a m. is weak,
with strengthening, (larger) & more meaningful activities are built.

As m. work is essential to → recovery of strength,

also overwork → loss of strength.

Fatigue & overwork must not be confused.

Fatigue is a normal & physiological reaction that

→ protects the normal individual from overwork.

Overwork is neither normal, nor physiological reaction,

So it’s a pathological reaction.
08/05/23 Ass. Prof. Salwa Roushdy 32
 Causes of Loss of M. Strength

 Decay of strength may occur in the m. groups not in use.

 M. re-education must encourage m. strength for effective fun.

of body segments (reverse of disuse).

 Orthotic devices as braces or corsets, are needed to:

1. Support weakened body seg.
2. Prevent deformity
But may →
a. Limit m. use
b. Cause m. weakness
Such disuse weakness can be determined by:
08/05/23 pain Ass.
& limited response of these ms. to specific activity.
Prof. Salwa Roushdy 33
 Usage of braces is a must in some situations where m.
can’t maintain supporting body parts.

If brace used all the time without periods of exercises

every now & then, it might be better not to use brace
because it might cause more weakness.

We use braces to help as fifty/ fifty % with our ms, if

we became reluctant on it 100%, our m will be more
weaker than before brace use. At that case better not
to use brace without strengthening program. (this is
the relation between m re-education & braces.

08/05/23 Ass. Prof. Salwa Roushdy 34

Isolation of Islands of Contractile Units .2
AHC disease

a. Denervation of individual m. f.

b. Areas of degeneration & fatty infiltration surround area of intact m. f .

It is common to see gradual ↓ strength in weakened m. during:

1st 6 months of acute poliomyelitis.

At that time, motor denervation can take place,

so protection of any additional weakness is made by:
preventing persistent stretching of the ms. (Brace usage).
08/05/23 Ass. Prof. Salwa Roushdy 35
 If the tendon is:

1. Contracted or
2. Abnormally lengthened

The normally moving m. can accomplish

a small part of effective mov.

08/05/23 Ass. Prof. Salwa Roushdy 36

 Prolongation of Rest Period Required for Recovery .4
 Rest periods for recovery is related to:

a. Fatigue
which is due to the accumulation of waste products,
which is in turn related to:
1. Blood supply.
2. Tissue drainage.

b. Individual motivation

 Strength may be achieved by:

1. Graduated active exs
2. Elect. M. Stim. (EMS).
3. Etc.,…
08/05/23 Ass. Prof. Salwa Roushdy 37
 III. Coordination
Is the integration of different kinds of movements in
a single pattern.

Is the ability to use the right m, at the right time & right intensity
to achieve a desired mov.

Coordinated patterns are:

those with which the neuromuscular & musculoskeletal systems
can most efficiently & safely function.

Is achieved through conditioned reflex training (subconsciously).

Coordination mechanisms are highly complex,

with many of the components of the movement at
a08/05/23
subconscious level beyond (out of) voluntary control.
Ass. Prof. Salwa Roushdy 38
 IV. Endurance
Definitions:

Ability to carry out repetitive mov essential to prolonged

activity.

Ability to repeat motor tasks or sustain motor activity over a

prolonged period of time.

Ability to maintain effort with demands placed upon the m.

* Patterns of mov to ↑ endurance are similar to that used to

obtain strength, except that the demands on neuromuscular
system are less.Ass. Prof. Salwa Roushdy
08/05/23 39
Ex. to ↑ strength require ↑ effort & ↓ repetitions.

Ex. to ↑endurance require ↑repetitions & ↓effort.

Endurance can also be developed by

↑ repetitions & R.

Strength without endurance is inefficient.

Strength & coordination without endurance are impractical.

08/05/23 Ass. Prof. Salwa Roushdy 40

 Examples
 According to the intensive evaluation, paralysis or severe
weakness with grade:

0: - ↑ sensory input by splinting, passive mov,

- interrupted direct currents.

1&2 but with intact nerve:

- passive mov, EMS (faradic & HVG), brief icing, brushing,
quick stretch, approximation, TVR, hydrotherapy, isometric
exs.
- Grade 1: static exs
- Grade 2: A A (suspension, sh wheel, finger ladder,
bicycle ergometer & PNF techs).

3,4 & 5:
- Active exs (AF, AR) via hydrotherapy, pulley, weights, slings,
08/05/23 biofeedback,Ass.
functional exs as up & down stairs, PNF, etc.,
Prof. Salwa Roushdy 41